Hepatic arterial reconstruction using saphenous vein graft interposition for distal pancreatectomy with celiac axis resection

Abstract

Objective: We report two cases required hepatic arterial reconstruction during distal pancreatectomy with celiac axis resection (DP-CAR). Methods: Case 1, 54 years old male patent underwent DP-CAR for his pancreas cancer. As radical antegrade modular pancreatosplenectomy (RAMPS) approach, Common hepatic artery was resected first then isolation of inferior pancreatoduodenal artery (IPDA) from supra mesenteric artery (SMA) was attempted. However IPDA was injured then hepatic arterial flow was lost. Total pancreatectomy and subtotal gastrectomy was performed to avoid pancreatic fistula and ischemia of the stomach. Then hepatic arterial reconstruction using saphenous vein graft interposition between infra-renal abdominal aorta and proper hepatic artery was performed. Case 2, 75 years old male patient underwent DP-CAR using RAMPS for his pancreas cancer. After lost hepatic arterial flow due to IPDA injury, saphenous vein graft was immediately harvested to minimize ischemia time. DP-CAR was performed and the stomach was preserved, then arterial reconstruction was performed as same as case 1. Results: Case 1, Hemorrhage from stomach stump was remarkable in his postoperative course. The patient is having malnutrition but not suffered from recurrence for 7 months after the surgery. Case 2, The patient developed delayed postoperative pancreatic fistula and bleeding from SMA. The patient died at postoperative day 82. Conclusion: RAMPS for DP-CAR may have a pit fall to keep hepatic arterial flow safe. The hepatic artery reconstruction using saphenous vein graft was feasible in our series. However reconstruction of the gastric arterial flow and minimize ischemia time should be considered for longterm prognosis.